Provider Demographics
NPI:1831179191
Name:MARTIN, JONATHAN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 TEXAN TRL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2547
Mailing Address - Country:US
Mailing Address - Phone:361-808-7200
Mailing Address - Fax:361-653-0431
Practice Address - Street 1:601 TEXAN TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2547
Practice Address - Country:US
Practice Address - Phone:361-808-7200
Practice Address - Fax:361-653-0431
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097438803Medicaid
TX8G6840OtherBLUE CROSS BLUE SHIELD
TX8533B9Medicare ID - Type Unspecified
TX8G6840OtherBLUE CROSS BLUE SHIELD